Over the past decade, there has been a significant increase in the number of physicians who have dropped out of Preferred Provider Organization (‘‘PPO’’) and Health Maintenance Organizations and have attempted to negotiate their own reimbursement schedules. With this growing trend we are beginning to see a wave of provider lawsuits begging for larger reimbursements.

Selection of a third party administrator (TPA) is crucial to the success of a self-funded plan. Criteria usually revolve around several factors including compatibility. Corporate philosophies of the employer and TPA should harmonize.

WASHINGTON — Just as millions of people are gaining insurance through Medicaid, the program is poised to make deep cuts in payments to many doctors, prompting some physicians and consumer advocates to warn that the reductions could make it more difficult for Medicaid patients to obtain care.

The Affordable Care Act (ACA) has had a fundamental impact on health care financing in this country. It has effectively provided added incentives for plan sponsors to consider modified self-funding arrangements for their employee health and welfare plans in lieu of fully-insured plans. The advantages of doing so are clear.

Hospital contracts, if you can get your hands on one, may prove too complicated for most. Page after page of legalese followed by five or six pages of reimbursement schedules makes for dull reading. On occasion one will be delighted to discover that some payers utilize a simplified, shortened version that even monkeys can understand.

ACS Benefit Services Inc. , a wholly owned subsidiary of BCBS of North Carolina, is a third party administrator active in marketing and administration of Referenced Based Pricing, Cost Plus Insurance plans.

“Providers across the country are experiencing a new “reality” in payment models where patients are presenting “Medicare PLUS” or “Cost PLUS” insurance cards, the latest tactic of self-funded, commercial employee benefit plans…….We’ve seen reimbursement levels range from 110% to 140% of Medicare….”

“HPC has developed a “dream team” of highly experienced medical claim negotiators and nurses………Future products include buying or building a PBM for our clients and operating it at cost. The goal is to shift the profits from PBM’s to Payers and their clients in the same way that we are doing with Large Dollar Claims.”

“Sex differences in risk seeking behaviour, emergency hospital admissions, and mortality are well documented. However, little is known about sex differences in idiotic risk taking behaviour………..Idiotic risks are defined as senseless risks, where the apparent payoff is negligible or non-existent, and the outcome is often extremely negative and often final.”

” It is conceivable that the sex difference is attributable to sociobehavioural differences in alcohol use. Anecdotal data support the hypothesis that alcohol makes men feel “bulletproof” after a few drinks….”

J. Patrick Rooney is the Godfather of Cost Plus Insurance. Rooney acknowledged that hospitals may need to charge more than Medicare will pay, but contended that authoritative research showed that Medicare plus 25 percent is the reasonable amount for hospitals to charge. J Patrick Rooney (1927 – 2008)

“Like our Medicare Based Pricing Product, Cost Charge Ratio Based Pricing offers a number of advantages over pricing based on a percentage off billed charges alone. Both eliminate excess charges due to providers artificially inflating their prices for services delivered.”

“Our clients are often speechless when we document what they are paying for hospital services after what they believe are the PPOs discounts…………………..On average we find payment levels of over 260% of Medicare and many times we find post PPO payments greater than 400% of Medicare………….”

AMPS is the leading and fastest growing Cost Plus / Reference Based Pricing company in the United States. Quick to react to market demands ( Xerox, Eastman Kodak And Cost Plus Insurance ) AMPS provides competitive pricing coupled with superior service.

“Companies must work constantly to eliminate any cost factor that does not add value to a business process” – Mike Dendy

Rising costs over the last decade have prompted many local governments to make changes to their health plans and strategies. Cost sharing, wellness program, and disease management initiatives are widely reported. Other changes cited include increased reliance on high-deductible plans, dependent eligibility audits, and altering retiree benefits.

I understand that you have very prestigious degrees and that this is a 5 year old post. However, this is why I felt compelled to comment. You should have known to prepare better, and this shouldn’t have been up for this long.

While you may have the “General Concept”, you clearly lack the requisite knowledge to understand the details behind MAC pricing, or any drug pricing logic for that matter.

Unfortunately, unbeknownst to most health plans, this MAC is far more pernicious than any oversized hamburger. In fact, PBMs insert the MAC concept into contracts in three ways to relieve health plans of millions in savings that they would otherwise obtain from using generic drugs over branded drugs.

Texas TPA’s are required to file an annual report to the Texas Department of Insurance to include current financial statement, total number of plans and employee lives along with biographical affidavits of officers and controlling shareholders. The FIN 486 Report includes Exhibits A-E.

“A recent RFP from a North Texas political subdivision specified only fully-insured health plans would be considered. They received two bids. The group was dismayed but felt better when told they received responses from 66% of the market” – Molly Mulebriar

Seasoned self-funders and advisors new to the world of self-funding will learn how to engage employers in compelling conversations that are quite different from the typical renewal discussion. Learn why premiums are just “CRAP.”

Sales is a profession. It entails a multitude of disciplines. Coping with continuous rejection and fear ensures the profession a steady procession of former salesmen. Those who overcome these weaknesses thrive. They are among the top earners in the country.

A successful salesman knows how to handle rejection. He has no fear of cold-calling. He is an expert observer and critical thinker. His powers of deduction are keen. He understands the importance of body language. He is patient and self-motivated. He listens. He has empathy. He is a problem solver.

When I asked a seasoned salesman in San Antonio to what he could contribute as to the basis of his success, he said “Molly, there are four principles, that if applied consistently, will lead anyone towards a successful sales career.”

“The share of the economy devoted to health care, which appeared to be growing inexorably for decades, has been the same since 2009…. Spending for health care in 2013 averaged $9,255 a person … Health spending grew at about the same pace as the economy and accounted for 17.4 percent of the gross domestic product, which reflects the total output of goods and services.” (The New York Times; subscription may be required)